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Page 6 of 9 Scotti et al. Mini-invasive Surg 2020;4:49 I http://dx.doi.org/10.20517/2574-1225.2020.38

Figure 3. Revised algorithm for secondary mitral regurgitation management in heart failure. Symptomatic, NYHA Class II-IV. Evaluation
of clinical context, symptomatology, etiology of MR, and MR severity using a multiparametric approach. *ESC/EACTS/HFA Guidelines;
§ACC/AHA/HFSA Guidelines. a: in patients undergoing CABG or AVR, ACC/AHA/HFSA Guidelines do not consider baseline LVEF in the
therapeutic decision-making process for concomitant valvular surgery; b: according to ACC/AHA/HFSA Guidelines, it is reasonable to
choose chordal-sparing mitral valve replacement for chronic severe ischemic SMR (COR IIa), whereas mitral valve repair or replacement
may be considered for chronic severe secondary MR (COR IIb) in patients undergoing isolated mitral surgery. ACEI: angiotensin-
converting enzyme inhibitor; ARB: angiotensin receptor blocker; ARNI: angiotensin receptor neprilysin inhibitor; AVR: aortic valve
replacement; CABG: coronary artery by-pass graft; CHF: chronic heart failure; COPD: chronic obstructive pulmonary disease; COR: class
of recommendation; CRT: cardiac resynchronization therapy; eGFR: estimated glomerular filtration rate; EROA: effective regurgitant
orifice area; GDMT: guideline-directed medical therapy; HF: heart failure; HFrEF: heart failure with reduced ejection fraction; HTx: heart
transplantation; LBBB: left bundle branch block; Log EuroSCORE: Logistic European System for Cardiac Operative Risk Evaluation; L-VAD:
left ventricular assist device; LVEDV: left ventricular end-diastolic volume; LVEF: left ventricular ejection fraction; MR: mineralocorticoid
receptor; NT-proBNP: N-terminal pro-B type natriuretic peptide; NYHA: New York Heart Association; SMR: secondary mitral
regurgitation; TAPSE: tricuspid annular plane systolic excursion. Adapted and modified from Godino et al. [7]

Despite these limitations, we can reasonably assume that most of patients with advanced HF exhibit
the classic pathophysiologic features of “true secondary” MR (proportionate MR) together with other
unfavorable co-pathologies (CKD, DM, AF, PVD and severe COPD). In these cases, a less favorable
response is to be expected after TMVR with MitraClip, because the underlying advanced cardiomyopathy
and the co-pathologies are not the direct target of the intervention. However, even the mere symptoms
reduction and the hemodynamic stabilization can be important goals for most of these patients and can be
achieved with the combination of GDMT and TMVR:

4. Advanced HF patients with proportionate MR aim for clinical and hemodynamic stabilization (or
improvement) as bridge therapy (the purple line in Figure 2).

To combine the current guideline recommendations based on available evidence together with the recently
published frameworks for MR and the unexplored setting of advanced HF, we propose a revised algorithm
for SMR management in HF patients [Figure 3] [7,23] .

MITRACLIP THERAPY IN ADVANCED HF PATIENTS
The aforementioned analysis of MITRA-FR and COAPT patients in conjunction with further investigations
will guide us towards the identification of who will benefit the most from TMVR and which is the proper